Rx for Fraud

Identifying prescription abuse via fraud analytics

March/April 2016

ByErwin Acuna, CFE; Erik Chase, CFE, CPhT

People are dying from drug overdoses in increasingly alarming numbers. They're from poor, middle-class and wealthy communities. The deaths have jumped in nearly every county just in the U.S. — driven largely by an escalating increase in addiction to prescription painkillers and heroin. That's according to a recent study by The New York Times. (See
How the Epidemic of Drug Overdose Deaths Ripples Across America, by Haeyoun Park and Matthew Bloch, January 19.)

Addicts are obtaining prescription drugs fraudulently in burgeoning numbers. The
U.S. Department of Justice (DOJ)
collected nearly $2 billion from health care fraud settlements and judgments last year. Of this, more than half was related to prescription drug fraud prosecutions and allegations driven by economic gain, diversion and/or abuse. The various entities that have committed prescription drug fraud include drug manufacturers, pharmacists, prescribers, patients and enterprising fraudsters.

Prescription drug fraud has both a health care and human impact. The economic cost derives from the high price of emergency services, prescriber visits, diagnostics, drug costs, loss of productivity, psychological treatment and legal expenses. The human cost includes the emotional stress that abuse and addiction inflicts on individuals and their families, loss of jobs, adverse health events (such as injury, HIV and hepatitis C) and, ultimately, the potential loss of life due to overdose.

The industry should employ fraud analytics to identify abusive patterns, which will allow clinicians to intervene to reduce this toll.

What is it about prescription drugs that attracts illegal behavior? The two major factors driving fraudulent activity are financial gain and abuse.

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